MEDICARE: JOSEPH DOMOWICZ P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	022450	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2432818	OTHER	NY	UNITED HEALTH CARE

General Provider Information

NPI Number	:	1114962388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH DOMOWICZ P.T.

Provider Business Mailing Address
First Line	:	413 86TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11209-4707
Country	:	US
Telephone Number	:	718-921-9721
Fax Number	:	718-921-9349

Provider Business Practice Location Address
First Line	:	4013 AVENUE U
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-5117
Country	:	US
Telephone Number	:	718-692-4100
Fax Number	:	718-692-0089

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2006
Last Update Date	:	07/08/2007

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